nov04.html

Nutrition Traineeship

e Journal Club

November 2004

This month we hosted four trainees from a variety of facility sizes
(250 beds to 1000 beds) and from a variety of geographic areas (Iowa,
Maryland, Ohio and Texas). We had a great week, and the slightly
bigger group lends itself to some nice discussions and sharing of case
studies and experiences.

Our article this month was from the November 2004 Clinical
Nutrition, and investigates the effects of delaying PEG placement on
patient mortality.

Summary:This study used two consecutive cohorts of patients admitted
with “malnutrition and terminal illness” who were referred for PEG
placement. The first group (January 1997 to December 1998) of 61
patients had PEG placement as soon as possible after the initial PEG
request (7 days +/- 6.8). The second group (January 1999 to December
2000) of 66 patients were scheduled for PEG placement 30 days
after discharge (16.6 days +/- 18.9).

The authors reported that delaying PEG placement for 30 days
(or more) significantly decreased overall mortality. The abstract
states that 30-day mortality was 40% lower in the group who had the PEG
delayed, and that mortality was 87.5% lower when it was calculated from
the time of PEG insertion.

Evaluation:
One obvious limitation of this study is that it was NOT a randomized
trial. These groups were separated by time, and it is possible
that some other factor, such as new techniques, new antibiotics, new
endoscopists, or other unknown factor could have influenced mortality
(History effect). In addition, there was no attempt to control
for severity of illness or underlying co-morbidities (diabetes, renal
failure, etc.) that could have influenced mortality.

Ultimately, only 3 patients in the “delayed-PEG” group did
not require their PEG because they were able to eat. When one
looks at the 90-day mortality of these two groups, the results are less
impressive. Based on the results in the figures it appears that
33 patients (50%) in the delayed-PEG group survived 90 days, while 18
patients (30%) in the early-PEG group survived for 90 days. This
difference would be worthy of notice if this were a randomized trial,
but the concern for selection or a history bias diminishes the impact
of this trial.

One factor that allowed this study to take place is the
location. This study was done in Israel, where the authors state
that all nursing homes allow patients with a nasogastric feeding tube
for a 30-day limit. A policy of delayed PEG placement may be
difficult in other parts of the world where the disposition of patients
with nasogastric tubes is more complicated. In addition, it is
unclear if the morbidity and mortality of those patients with a
nasogastric tube would be this low in all nursing homes. Adequate
staffing and supervision of patients are required to prevent adverse
effects from partial dislodgement of nasogastric tubes while feeding in
this population.

Take home message:

The results of this study are worthy of notice. In this era of
rapid discharge we should consider if there is a better timing of PEG
placement in a population that is frequently debilitated and
elderly. However, the limitations of the study design are real,
and therefore we would need to see a randomized study before we would
consider any type of policy change regarding the timing of PEG
placement. In addition, the environment of the study (nursing
homes in Israel) may limit the practicality of such a policy in other
places.

Finally, despite its flaws this study does remind us that perhaps
there should be better criteria for patient selection when it comes to
PEG placement – just because we have the ability to keep patients
hydrated and nourished, does not mean that we should always do
so. Perhaps there are some patients that we should not burden
with this procedure.

“The greatest obstacle to discovery is not ignorance -- it is the
illusion of knowledge.”